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City of Everett Use Only RECEIVED 04n TORT CLAM FORM OCT 01 2013 Rev.07/09 CITY Pursuant to Chapter 4.96 of the Revised Code of Washington (RCW), OFVETT this form Is for filing a tort claim against the City of Everett. Some of City Clerk the information requested on this form is required by RCW 4.96.020 and may be subject to public disclosure. The City Clerk is the City's Cily Clerk Claim No. designated agent for the purpose of receiving claims. Claim forms r)20 — cannot be submitted electronically(via e-mail or fax). 6 of 3.0014563 P EASt tO _ Yi ItittARLY"IN 1Nk Mail or deliver original signed claim form to: Office of the City Clerk City of Everett Business Hours: 2930 Wetmore Ave.,Ste. 1-A Mon.—Fri.,8 a.m.to 5 p.m., Pacific Time Everett,WA 98201 Closed on city holidays I CLAIMANT INFORMATION: 1. Claimant's name: Vi e.11. o rs P ( 16 1167 Last name First ids - Date oblrtil(mm/dd/yyyy) 2. Current residential address: I. "'" 3 � ? 'Ve e c�vJ q: ja.Q 3. Mailing address(if different): Ns IA 4. Residential address at the time et the Incident(if different from current address): ( [(I - 5 Pi E c e.-�~ �>� e ab3 5. Claimant's telephone number: tla a 3 I Home Cell Business 6.Claimant's e-mail address: N J INCIDENT INFORMATION: 7. Date of incident: 06'jail Time „ t�t3 ❑ a.m. UKrn. (check one) (mm/.d/1110 8.If the incident occurred over a period of time,date of first and last occurrences: from: Time: ❑,a.m. 0 p.m.(check one) to Time: 0 a.m. 0 p.m.(check one) (mm/dd/yyyy) (mm/dd/yyyy) L.4nII �) 9. Location of incident: t_ �1g�1/••E'/`�" - "I.yt�i'V�E'i Q.i70t State and coufty City,ifapplicable Place where occu red 10. If the Incident occurred on a street or highway: NIA Name ofstreet or highway At the Intersection with or nearest Intersecting street Rev.07/09